01020082 CITY OF CUPERTiNO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADIIRI?SS: ITRMIT NO.
J
OA
UW NIiH'S NAMf:;^ . GENERAL 1—IGHTING APPLICATION SUII LAM,
f975 GHIEST-Ifil-IT
:•
PHONC: SAN,'rARY NO. CONTROL NO.
M 0 fe-O ARCHI"rECT/CNGINEP.R: BUILDING PERMIT INPO
RU
OPLUMB SjlC
N CLDG t r:LOCI' IJ I.
O'ate^j ,JG3NS110 CONTRACTOR'S Ufc1.ARA'I ION Job Description
0 Z✓,J 1 hercny nllirm Iha ma Ileen,cJ nude,novi,ionv,or Chupmr,9(annmcnaing
FyCW w hit Socha,7010)or Divi n,3ollhe Bueincv,m [for ,audvor It"n,e
pxgwl iv in full fvrecand cue — O
zaa License Class CHANGE LIGHTS & NEW AC, TI
6 V nate cnmmetnr
w 3 w ARCIIRLCI"S IlIiCm 1'I
F=C I 1 nJ t J ny pl hall he used p M N.v
I r
w—CO Lvcn Jw oI
c �� `
OWNI H HIJILOER DCCT ANAI'ION
11 by br lotiontihat 1 pr I mor I In,( 1'cl :Core, I fin'.
Cly Bllow b fS colli WItIrmi.ales II f xAy it,an nommen,
yO winchml,r,o apermit mnm..thicppli..vm,pnor.Jernar tot nre.,irmytwe vot
i3- pat he isvicensed omenalso tquims thaapphcanl for mcnpthar'% icense ne(Cte erg
that nmenh«used moment tnm))of Of,W ofthecanlro es,andn.ehw(cnarver9 Sy. Ft. Floor Area Valuat' n
or that a iv a with t Inuml 7(010 of Division J of the tend x mp Frmion.Any vt tatitm
m that he ie exempt rhertl'mrn and the basis for the ellegN exemption.Any vinlatinn
or Sachnn 703 1.5 by any applicant for a permit subjects the applicant to a civit penally
of nm mo.than fiec handrtdno,mrv(s5w). APN Number Occupancy ype
❑1,a,owner of the property.or inti cmployces will,wage ar,their sale campm.niion.
w111 do the work,and the nvuhrm is not Intcod,d or offered for nate(Sec.9144. ��.
Bu,imea,tuna Prnfn,,;nn,CadcrIhe Contractor,1.i4rrr,r Law doe,mot apply m a„ 0 • equired Inspections
orr or prapcny Who h ii tin or improves Ihcrnm,and who docs such work Iamselr
thmu5h his awn mnplayces.provided that wch Improv liner are not intended or
oaered tor ale.B.however,the building or improvement is%old within ane year of 101 — FOUNDATION
completion,the owner-builder will have the burden of proving that he did not hold or
improve for pmrose onmca. 102 — PIERS
C)Lav r of the propcoy.n excluv;vely contorting with licensed contractors to 103 — UFE R
iconstruct projta(Sec.7041.Business and Profe„ioov C(de:)"c Cnmmcmrx 104 — REAR R
1.ew die,nor mq,ly n,an ovum of property wen nniid,o,;rnpromn mmraor.
Bod who ram,ao, for,nth voyO,„im:r,mv,a,l l i,cv,,ed no,ruam or nom 105 — ANCHOR BOLTS
anmarva,Uconvc Low.
0 l am rxemp,never Set. .B&P C ea this rta""n ].OE, — SEWER & WATER
Culler Dale 202 — UNDERFLOOR PLUMBING
WORKCR'S COMPCNSA11ON DECLARATION
I hemhyafirm,under penmtyor pchyryoneol be,,ouoam,decmmam,n: 203 — UNDERFLOOR MECHANICAL
0 1 have and will nmhma;lir a certificate of consent to wh:in,are for Worker', 204 — UNDERFLOOR FRAME
C.....pe..vminm as provided rot hrseetion retro or be Labor Code, for the 205 — UNDERFLOOR INSULATION
IDrlf have and will maim n Wndar'vhCo i,cmn,;,wed301 — ROUGH PLUMBING
.
tion h„mamtr.as oatmeal by Section
3700 of me Lrmo 0.lc.for me N,(ortnance ni he work.lo,which,hi,permil 1, 302 — TUB & OR SHOWER
ismed.M lis Compen,alon Insumnte ca,r.1 J Policy number :
caroler: �O�- Pvhc,Nv,., i Od 6066 30'0 303 - ROUGH MECHANICAL
CERI'IRCKETC) OFI?KEMPl(0) tR MWORKERS' 304 — ROUGH ELECTRICAL
COMPCNSATION INSURANCE
305 — FRAME
('rhe,rection nreA urn nu cnn,pleted If Inc Perurir is Iia one Hundred Aullua
(Mon)m1nr.) 30E — HOI_DOWNS
I trolly that in the performance of he work for which this permit is i„ora.1 307 — INSULATION
,hull it emNoy any pervon many manner so u,to bee...ne nbjrul m the worker X08 — SHEET ROCK,
Comfwnrwlion laws of California.Date v
A,hcam
NOTICE TO APPLICANn If,after making this Certificate of Exemption.you should 309 — EXTERIOR LATH
Mcmm,ubject to me WorkersCom,ron.aaon provision,ohne Labor node,yin mart 31.0 — INTERIOR LATH
0 tonhis ah complywile such Pnw mor,or thin penvil.hall be deemed revoked.
V] CONSI'NUC'rION LEN DING AGIiNCy 311 — SCRATCH COAT
Ilmrehyarlim,annirm is a covort"in i loading ngrncy for theft vi'voe —
a drat,work for wroth hi,,vnmil i,lowed(See.3097.Civ.C.) 313 ROOF NAIL
y q l<m,rvName 501 — FINAL ELECTRICAL ENERGY
7 7 Lender*,Addm,s _
U O 1 cndrmm l nage rev mU apdivini—and.mm that the above information is 502 — FINAL PLUMBING ENERGY
;a. [�_, cornet.Iagreelocompywithallcityandcountyordinariand%latelaw,relating 503 — FINAL MECHRNICAL ENERGY
0 V to building construction,and hereby anmorWrepm,cho v,of this city m coli v,m
y the:,Bove.mentiemdpropcoyfornopectionpamo,eo. 504 — FINAL BUILDING ENERGY
CL, (We)ag,relo,a,crm,emody and keep ho,mdrx, he C;trorenprn'mo agairat
m uahuhie,.'magrnrr,t.,to,a,rrm<xper„eswhitl,,marir,artywarattmeug:ar,.r,ria OS — FINAL ELECTRICAL
U chr m. amore of asp guoo,do,g dun's perm,,, - i/ o r
.I PNTG PDC ti'IANDSA WILL 0 'hV WI'T'H ALL NON�MIINf Issued by: J GAS TEST pate 2
gra rt n conGae, batt Re-roots
HA%rhurn, Mdi.,oc ISUhumosORE 508 — FINAL MECHRNICAL
ail me a Cu,,ert nt fMari wilding e.Chart humor nnm,he namw,anmacdm Type of Roof
C de.Std iby on 25 Cupeninn Municipal Code.Charter 9.12.and the Health and Safety 509 — FINAL GRADE
Cala.Station 355)2141"
El Yr, El No All roofs shall be rtttoticsd pIF,,Jr1`49hnyPrXr4 {1P;YRial being installed.
WillmeapoirarrNe.....ier,torn<mitr,which If a roof in installelliVihoutlF'ritla tin lll'iglja{-ill�peclelQ 4� lice to remove
en,h rrudau,4i,m..air 1,a,defined by the Bay Are:t Air Quality M:u agermetn
iardmp all new materials for inspection. Applicant understands and will comply with
OYe, 0 N all non-point source regulations.
1 have mad,he l,aeadnu,matedilv mqulrtment,under Chapter 6.95 of the
Cnlifomia Health 3 Safny Codc.Sections 25505.25531 and 25534.1 understand than
ifhweal
buildingdcomenlyhvea
rccmentwhich trhaentm,tehtapt it irv my wpaudnssiobfilalry Cmennin,ithifayt thoef
),
Signature of Applicant Date
ww All roof coverings to be Class •B”or better
OFFICE